Away Rotation Applications in Emergency Medicine: Medical Student Behaviors, Outcomes, and Stressors

Background: Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. Objectives: We conducted a survey study of EM-bound fourth-year medical students to gain insight into their AR application experiences, outcomes, and perceptions. Methods: We distributed a 40-item questionnaire to EM applicants in Fall 2018 via e-mail through the Clerkship Directors in Emergency Medicine, Council of Residency Directors in EM, and Emergency Medicine Residents\u27 Association listservs. Responses were evaluated using quantitative and qualitative analysis. Primary outcomes were the number of AR applications submitted and AR offers received by students. Secondary outcomes were students\u27 self-assessment of their competitiveness, differences in AR application numbers by degree type, sources of student advising, and student perceptions of the AR application process. Results: There were 253 respondents, consisting of 192 allopathic (MD) and 61 osteopathic (DO) medical students, who met the inclusion criteria, representing about 10% of the applicant pool. On average, students submitted 13.97 applications (95% confidence interval [CI] 11.59-16.35), received 3.25 offers (95% CI 3.01-3.49), and accepted 2.22 offers (95% CI 2.08-2.36). DO candidates submitted twice as many applications as MD candidates while experiencing a similar rate of offers received. Peer influence (n = 154, 61%), peer online advising networks (n = 83, 33%), and self-assessment (n = 114, 45%) were the most often reported causes of increased applications; cost (n = 104, 41%) and geographic limitations (n = 114, 45%) were the most often reported causes of decreased applications. Open-response analysis revealed frustration with lack of standardization (n = 44, 29.5%), insufficient transparency on available positions (n = 37, 24.8%), limited communication (n = 30, 20.1%), and cost (n = 12, 8.1%). Conclusions: This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status. Keywords: VSAS; VSLO; Visiting Student Application Service; Visiting Student Learning Opportunities; advising; application; audition rotation; away rotation; emergency medicine; sub-internship

Audience Response System Facilitates Prediction of Scores on In-Training Examination

INTRODUCTION: Audience response systems (ARS) are increasingly popular; however, their contribution to education is not completely clear. Our study found that scores from review quizzes delivered by an ARS correlate with in-training exam (ITE) scores and are viewed positively by residents. This information may be useful in identifying poor performers early so that targeted educational interventions can be made. The objective was to determine if scores on review quizzes delivered by an ARS correlate with ITE scores and to obtain participant feedback on use of the ARS for ITE preparation. METHODS: This was a prospective observational study of emergency medicine (EM) residents at six accredited EM residency programs. Subjects included residents who had taken previous ITEs. Subjects participated in bimonthly review sessions using an ARS. Twelve review quizzes were administered, each consisting of 10 multiple-choice questions. After the ITE, subjects completed an attitudinal survey consisting of six Likert-scale items and one yes/no item. We used a mixed linear model to analyze the data, accounting for prior 2012 ITE scores and nesting due to institution. RESULTS: Among 192 participants, 135 (70.3%) completed the ITE in both 2012 and 2013; we analyzed their data for the first objective. Results from the mixed linear model indicate that the total mean score on the review quizzes was a significant [t(127) = 6.68; p \u3c 0.001] predictor of the 2013 ITE after controlling for the 2012 ITE score. One hundred forty-six (76.0%) participants completed the attitudinal survey; 96% of respondents stated that they would like ARS to be used more often in resident education. Respondents felt the sessions aided in learning (mean 7.7/10), assisted in preparation for the ITE (mean 6.7/10), and helped identify content areas of weakness (mean 7.6/10)

More Is More: Drivers of the Increase in Emergency Medicine Residency Applications

Introduction: The average number of applications per allopathic applicant to emergency medicine (EM) residency programs in the United States (US) has increased significantly since 2014. This increase in applications has caused a significant burden on both programs and applicants. Our goal in this study was to investigate the drivers of this application increase so as to inform strategies to mitigate the surge. Methods: An expert panel designed an anonymous, web-based survey, which was distributed to US allopathic senior applicants in the 2017-2018 EM match cycle via the Council of Residency Directors in Emergency Medicine and the Emergency Medicine Residents Association listservs for completion between the rank list certification deadline and release of match results. The survey collected descriptive statistics and factors affecting application decisions. Results: A total of 532 of 1748 (30.4%) US allopathic seniors responded to the survey. Of these respondents, 47.3% felt they had applied to too many programs, 11.8% felt they had applied to too few, and 57.7% felt that their perception of their own competitiveness increased their number of applications. Application behavior of peers going into EM was identified as the largest external factor driving an increase in applications (61.1%), followed by US Medical Licensing Exam scores (46.9%) - the latter was most pronounced in applicants who self-perceived as less competitive. The most significant limiter of application numbers was the cost of using the Electronic Residency Application Service (34.3%). Conclusion: A substantial group of EM applicants identified that they were over-applying to residencies. The largest driver of this process was individual applicant response to the behavior of their peers who were also going into EM. Understanding these motivations may help inform solutions to overapplication

Academic Emergency Medicine Physicians\u27 Knowledge of Mechanical Ventilation

INTRODUCTION: Although emergency physicians frequently intubate patients, management of mechanical ventilation has not been emphasized in emergency medicine (EM) education or clinical practice. The objective of this study was to quantify EM attendings\u27 education, experience, and knowledge regarding mechanical ventilation in the emergency department. METHODS: We developed a survey of academic EM attendings\u27 educational experiences with ventilators and a knowledge assessment tool with nine clinical questions. EM attendings at key teaching hospitals for seven EM residency training programs in the northeastern United States were invited to participate in this survey study. We performed correlation and regression analyses to evaluate the relationship between attendings\u27 scores on the assessment instrument and their training, education, and comfort with ventilation. RESULTS: Of 394 EM attendings surveyed, 211 responded (53.6%). Of respondents, 74.5% reported receiving three or fewer hours of ventilation-related education from EM sources over the past year and 98 (46%) reported receiving between 0-1 hour of education. The overall correct response rate for the assessment tool was 73.4%, with a standard deviation of 19.9. The factors associated with a higher score were completion of an EM residency, prior emphasis on mechanical ventilation during one\u27s own residency, working in a setting where an emergency physician bears primary responsibility for ventilator management, and level of comfort with managing ventilated patients. Physicians\u27 comfort was associated with the frequency of ventilator changes and EM management of ventilation, as well as hours of education. CONCLUSION: EM attendings report caring for mechanically ventilated patients frequently, but most receive fewer than three educational hours a year on mechanical ventilation, and nearly half receive 0-1 hour. Physicians\u27 performance on an assessment tool for mechanical ventilation is most strongly correlated with their self-reported comfort with mechanical ventilation

Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study

Aim: To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. Methods: This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects \u3e14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression estimated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. Results: Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure \u3c100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation \u3c90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. Conclusions: Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are needed to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest. Keywords: Adverse Event; Airway; Hypotension; Hypoxemia; cardiac arrest; intubation; mortality

International Medical Graduate Advising Recommendations From the Council of Residency Directors in Emergency Medicine Advising Student Committee

International Medical Graduate (IMG) physicians applying to residency training programs in a country different from where they completed medical school, bring beneficial diversity to a training program, but also face significant challenges matching into an Accreditation Council for Graduate Medical Education (ACGME)-accredited residency program. Despite the growing number of IMG applications in Emergency Medicine (EM), there is a paucity of targeted recommendations for IMG applicants. As a result, the Council of Residency Directors (CORD) Advising Students Committee in EM (ASC-EM) created a dedicated IMG Advising Team to create a set of evidence-based advising recommendations based on longitudinal data from the National Residency Match Program (NRMP) and information collected from EM program directors and clerkship directors. IMG applicants should obtain at least two EM standardized letters of evaluation (SLOEs), review IMG matched percentages for programs-of-interest, analyze their objective scores with the previous matched cohorts, and rank at least 12 programs to maximize their chances of matching into EM. Keywords: advising; emergency medicine; international medical graduate